Mucinous appendiceal neoplasms: Report of a case and brief literature review.

INTRODUCTION: Appendiceal tumors are rare neoplasms detected in about 2 % of appendicectomies. The clinical presentation is often unspecific, varying from unspecific abdominal pain or presenting as an acute appendicitis or being asymptomatic. CASE PRESENTATION: We present a case of a patient presenting as an acute appendicitis with a mucocele, and then classified as HAMN. The patient was treated with initial laparoscopic approach and then conversion in laparotomy with appendectomy. Histology demonstrated a high grade appendiceal mucinous neoplasm limited to submucosa (pT3), with concomitant acute phlegmonous appendicitis. The patient was subsequently sent to a referral center where a right hemicolectomy with HIPEC was performed. DISCUSSION: HAMN is a rare entity, only recently classified as a new kind of appendiceal mucinous neoplasm. Due to the supposed higher aggressivity, HAMN must be treated as an appendiceal adenocarcinoma. The treatment of this rare entity is not yet well standardized, because of the rarity of this disease. CONCLUSION: HAMN is a very rare tumor. In the emergency setting, it is mandatory to avoid rupture of the appendix, to minimize the risk of developing pseudomyxoma peritonei. Pathology is essential for further decisions in these patients and plays a very important role in treatment and prognosis.

A rare case of pneumatosis cystoides intestinalis with bowel perforation and secondary sepsis.

MATERIALS AND METHODS: We present here the case of an 83 y.o. male with intestinal perforation from pneumatosis cystoides intestinalis and consequent sepsis. RESULTS: The patient underwent urgency intestinal resection in our institute, with complete restitution ad integrum Discussion: Pneumatosis cystoides intestinalis is a rare affection, which can be categorized as primary (15%) or idiopathic( 85%). The clinical appearance can be very variable from patient to patient, since it can be completely asymptomatic or start with life-threatening clinical presentation of bowel perforation and sepsis. There are various theories about the formation of the gas bubbles trough the intestinal wall. The mechanical theory assumes that the gas, tearing trough the intestinal wall seeps trough it. The bacterial theory assumes that antibiotic treatment, such as with metronidazole, allows the creation of gas by microbiological elements like Clostridium Perfringens or Clostridium Difficile. The pulmonary theory, instead, assumes that air released from ruptured alveoli gets into the mediastinum and retro peritoneum, reaching the intestinal tract. The treatment is conservative most of the times, except for the cases of intestinal perforation and sepsis. CONCLUSIONS: Despite of the long history of the disease, with the first description in 1783, little is known nowadays about PCI, due to the rarity of symptomatic disease. Further studies are needed to better evaluate the aetiology of the condition, and the prognostic criteria, which may be very important for clinical decisions about conservative or surgical treatment. KEY WORDS: Diagnosis, Pneumatosis cystoides intestinalis, Peritonitis, Therapy.

The "Watch and wait" approach following chemoradiotherapy for rectal cancer: a case series and review of literature.

Neoadjuvant chemoradiotherapy (NCRT) combined with total mesorectal excision (TME) is currently the gold standard for locally advanced low-lying rectal cancer (LACR). Around 20-30% of patients after NCRT can achieve clinical complete response (cCR); 5-44% of the patients who underwent TME achieve pathological complete response (pCR) on postoperative histopathologic studies. In the present study we perform a review of current Literature and retrospectively analyze our personal experience on "watch and wait" approach after cCR. Further studies are needed to establish an internationally accepted definition of clinical complete response, to delineate the real role of MRI in the post-treatment staging and to determine more precise predictors of sustained clinical complete response. The eventual presence of long-term morbidity and adverse effects after chemoradiation needs as well to be better evaluated. Evidence suggests that watch and wait approach is associated with substantially better quality of life and functional outcomes compared with standard surgical resection. KEY WORDS: Chemoradiation, Neoadjuvant therapy, Rectal cancer, Remission induction.

Cholecystogastric fistula. A case report and literature review.

Cholecystogastric fistulas is a rare complication of gallstone. Even if well described in the literature, this condition still poses a debate on diagnosis and surgical treatment. We present a case of a 35 year's old female which unexpectedly presented a cholecystogastric fistula during a laparoscopic cholecystectomy, treated successfully with fistula transection and repair and cholecystectomy through an open access. The open access remains the preferable option in this cases but laparoscopic techniques are being used worldwide with increasing success. The preoperative diagnosis remains difficult for the unspecific symptoms. KEY WORDS: Biliodigestive Fistula, Gallstone Ileus, Gastric Fistula, Biliary Fistula, Cholecystitis.

Extragenital malignant mixed mesodermal tumor: A case report.

INTRODUCTION: Primary malignant mixed mesodermal tumor (MMMt, also called malignant mixed Mullerian tumor and designated in the WHO classification of female genital tract neoplasms as carcinosarcoma) is an infrequent tumor that develops usually in the uterus and more rarely in the ovary. Extragenital tumor, including primary peritoneal MMMt, is an extremely rare and aggressive neoplasm with only few case reported in the literature. PRESENTATION OF CASE: We report a case of a 70-year's old female who presented with nausea and abdominal discomfort for 6 months. Workup revealed an abdominal mass. Patient was treated with surgical removal in a general hospital. DISCUSSION: Most peritoneal carcinosarcomas originate in the pelvic peritoneum, followed by decreasing frequency in the serosal surface of the colon, retroperitoneum, anterolateral abdominal peritoneum, and omentum. Surgical excision is the most effective treatment in carcinosarcomas. A complete cytoreduction, with resection of cancer to a status of no evidence of disease by the surgeon's unaided eye should be attempted. CONCLUSION: Owing to the rarity of the disease, limited data regarding the management of peritoneal MMMT exists. Recommendations for the treatment of MMMT are based on individual cases only. In our case, the patient is alive with a follow-up of 15 months and she did not receive any cycle of chemotherapy.

Laparoscopic sleeve gastrectomy versus intragastric balloon: a case-control study.

AIM: To compare the efficacy of laparoscopic sleeve gastrectomy (LSG) and BioEnterics intragastric balloon (BIB) to lose weight and comorbidities after 12 months of follow-up before a more invasive bariatric procedure. METHODS: From January 2004 to December 2006, 40 patients underwent laparoscopic sleeve gastrectomy (LSG) as a first step in biliopancreatic diversion with duodenal switch. Controls (n = 80) were selected based on charts of patients who, during the same period, underwent BioEnterics intragastric balloon therapy. In both groups we considered: length of procedure, hospital stay, intraoperative or endoscopic complications, postoperative or postendoscopic complications, comorbidities at baseline, after 6 months (time of BIB removal), and after 12 months from baseline, and weight loss parameters [weight in kg, percentage excess weight less (%EWL), body mass index (BMI), and percentage excess BMI loss (%EBL)]. Results are expressed as mean +/- standard deviation. RESULTS: Mortality, intra- and postoperative complications (in LSG group), and intra- and postendoscopic complications (in BIB group) were absent. Mean operative time in the LSG group was 120 +/- 40 (range 60-200) min. Mean positioning time for BIB was 15 +/- 5 (range 10-25) min. BMI at baseline was 54.1 +/- 2.9 (range 45.1-55.9) kg/m(2) and 54.8 +/- 2.5 (range 45.1-56.2) kg/m(2) in BIB and LSG groups, respectively. At 6-month follow-up, mean BMI was 46.2 +/- 3.5 and 45.3 +/- 5.5 kg/m(2) in the BIB and LSG patients, respectively [p = not significant (ns)]. After 12 months BIB patients regained BMI, even if strictly followed with a diet regimen, while LSG patients continued to lose weight. Significant differences between groups were absent for the comorbidities considered. CONCLUSIONS: Laparoscopic sleeve gastrectomy and BioEnterics intragastric balloon are two valid options for producing weight loss as a first-step procedure. LSG has all the related risks of general anesthesia, laparoscopic surgery, and digestive anastomosis, whereas BIB presents a very low rate of minor complications, such as psychological intolerance. For all these reasons, at this time, BIB is considered a better option than LSG as a first-step procedure in the short term (12 months).